Cardiac simple nursing quiz
A client with stage 1 hypertension appears at the clinic for follow-up. The patient's BP is 138/88 mm Hg. The patient asks why it is important to treat hypertension. What would be the nurse's best response? "Hypertension causes relaxation and dilation of arteries which strains the heart." "Hypertension if unchecked increases risk of adult onset of Type 1 Diabetes." "Hypertension is the leading cause of death in people your age." "Hypertension greatly increases your risk of stroke and heart disease."
"Hypertension greatly increases your risk of stroke and heart disease." Hypertension increases the risk of stroke and heart disease and persons with Stage 1 may progress to Stage 2 unless lifestyle changes are taken to control the blood pressure. Hypertension does not dilate arteries, but causes vascular resistance vasoconstriction. While insulin resistance and metabolic syndrome may lead to increased sympathetic activity and hypertension, it does not increase the development of insulin dependent diabetes (Type 1).
The nurse is caring for a client with complaints of claudication. An ankle-brachial index (ABI) is ordered and the client asks what the test measures and why it is important. Which statement by the nurse best describes the ABI? "The ankle-brachial index is a noninvasive procedure to check your risk of peripheral artery disease." "The ankle-brachial index produces a ratio of SBP with retrograde wave reflection from resistant distal arterioles." "The test is a physician ordered exam, but nothing compares to old fashion palpation of your pulses." "The test is no big deal. Don't worry about anything as results can be misleading."
"The ankle-brachial index is a noninvasive procedure to check your risk of peripheral artery disease." The best explanation for the client is that ABI is noninvasive and is used to check risk of PAD. The second response utilizes medical terminology which is not the best choice in providing instruction to clients. Response C is incorrect and may hinder the nurse/physician/client relationship since the nurse may disagree with the need for the ordered procedure. The nurse should never respond with statements of false reassurance and doubt as depicted in answer D.
The nurse is caring for a patient who is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). Which information by the nurse best explains the procedure? "The procedure involves attaching grafts to replace blocked coronary arteries." "The procedure includes threading a catheter with a sharp blade at its tip to scrape plaque build-up." "The procedure involves opening a blocked artery with an inflatable balloon located on the end of a catheter." "The procedure involves a catheter with monitor on its tip which will stay in place during open heart surgery."
"The procedure involves opening a blocked artery with an inflatable balloon located on the end of a catheter." PTCA involves insertion of a balloon-tipped catheter into the coronary artery to compress a plaque, thereby opening a stenosed or blocked artery. The first answer describes coronary bypass graft surgery and the second answer describes a procedure called atherectomy where plaque is removed through a catheter-ended blade or burr. The procedure does not include placing a monitor on the tip of a catheter for surgery visualization.
The nurse is caring for a client admitted for acute pericarditis. Which nursing diagnosis should take priority during the first 24 hours of nursing care? Risk for falls related to weakness, pain, and dizziness Acute pain related to inflammation of the pericardium Imbalanced nutrition: less than body requirements related to decreased intake, nausea and anorexia Activity intolerance related to fatigue and physical weakness
Acute pain related to inflammation of the pericardium Relief of chest pain is one of the prioritized nursing diagnoses. Pericarditis causes severe pain with rapid onset that worsens with breathing, coughing, and/or changing positions. Such pain prevents ability to help respiratory efforts. It worsens as excessive accumulation of fluid in the pericardial sac occurs. The result is decreased stroke volume and compression of the heart. While risk for falls, activity intolerance, and imbalanced nutrition may be a part of the plan of care, pain affects the heart and oxygenation.
The nurse is assessing a client admitted to the telemetry unit from the Emergency Department with complaints of increasing shortness of breath, and is coughing pink-tinged frothy sputum. During the history assessment, the nurse documents a history of left-sided heart failure. The nurse recognizes the presenting signs and symptoms of which health problem? Right-sided heart failure Acute pulmonary edema Bacterial Pneumonia Myocardial Infarction
Acute pulmonary edema Left-sided heart failure is manifested in the pulmonary system and may produce signs of pulmonary congestion, which may lead to congestive heart failure. If the left ventricular system fails to eject blood, then lung pressure rises as a result of pulmonary edema. Cardiogenic causes of pulmonary edema are due to poor heart function and result in congestive heart failure. Other causes (non-cardiogenic) are from acute respiratory distress syndrome, trauma, kidney failure, and other causes. The other selections do not coincide with assessment of history (hx of left HF), and signs such as blood-tinged, frothy sputum. Right-sided heart failure presents with dependent edema, jugular distention, hepatomegaly, weight gain, and abdominal distention.
The nurse is providing education to a client with a history rheumatic heart. Information includes risk factors for bacterial endocarditis. The nurse asks through teach-back if the client knows the importance of taking which of the following drugs prior to scheduled invasive procedures? Amoxicillin (Amoxil) Solumedrol Warfarin (Coumadin) Metoprolol (Lopressor)
Amoxicillin (Amoxil) Client education in prevention of bacterial endocarditis in clients with history of rheumatic heart disease includes teaching about taking prophalaxis antibiotics to prevent vegetation and spread of bacteria from one area of the body to the heart. Dental procedures and other invasive treatments may require use of antibiotics. Most common antibiotics are amoxicillin, ampicillin, cephalexin (if allergic to PCN or ampicillin), clinamycin, or azithromycin.
A client is brought to the emergency department (ED) by family for unrelieved chest pain for 45 minutes. Which of the following interventions are most important? Administer oxygen, give a dose of NTG sublingual, and follow with a nonsteroidal anti-inflammatory. Begin a heparin drip, administer oxygen, and call the lab for stat troponin levels. Apply oxygen, administer morphine sulphate, and place client on bed rest with cardiac monitoring. Have the client to chew two aspirin 325 mg each, administer oxygen, and bring the crash cart to the bedside.
Apply oxygen, administer morphine sulphate, and place client on bed rest with cardiac monitoring. A patient with suspected myocardial injury should have oxygen available, morphine, and should be on bed rest. Morphine reduces preload and decreases workload of the heart, while bed rest will reduce workload and oxygen needs. These actions will decrease cardiac demand. NTG and aspirin are also used in the ED; however, the selections include giving an NSAID, and having the crash cart moved to the room. The ED area will already be equipped for emergency care if needed. The client may have an anticoagulant provided IV, but the emergent priority is to decrease cardiac demand.
A nurse is caring for a patient who returned from surgical popliteal bypass graft procedure. A priority assessment during the first 24 hours will include: Assess pulse of affected extremity every 15 minutes, followed by agency policy. Palpate the affected leg for pain and venous return during every assessment. Assess the patient for signs and symptoms of compartment syndrome every 2 hours. Perform Doppler evaluation once daily.
Assess pulse of affected extremity every 15 minutes, followed by agency policy. Assessment of affected extremity every 15 minutes, followed by agency policy is recommended after surgical popliteal bypass graft. Assessment of blood flow with regular frequency immediately post-surgery and for 24 hours thereafter will provide neurovascular assessment. Palpation of affected leg is contraindicated, and compartment syndrome occurs with injured tissue usually the result of injury. While Doppler evaluation may occur, the client is post-operative and requires more frequent assessment.
The nurse is assessing an elderly client admitted with a diagnosis of chronic heart failure (HF). The spouse asks the nurse the primary cause for HF, and the nurse responds that HF may be caused by: Endocarditis Pleural effusion Atherosclerosis Atrial-septal defect
Atherosclerosis The progressive buildup of plaque, inflammatory cells, and other substances that adhere to the cell wall may narrow arteries and affect arterial dilation and expansion and ability to carry blood supply resulting in coronary artery disease (CAD). Atherosclerosis is a main condition associated with age and HF. Endocarditis is caused by an infection of the endocardium (usually bacteria, fungi, and from migration of bacteria from other parts of the body). While endocarditis may have complications if left untreated, it does not fit the diagnosis for chronic HF. Pleural effusion is a collection of fluid in the pleural space, and may arise from cardiopulmonary disorders or systemic inflammatory disorders (such as cancer); however, is not primary cause for chronic HF. Although atrial septal defects may result in HF, manifestation may occur from infancy through early childhood, and adults with undetected atrial septal defects may also have pulmonary hypertension, shortened life span, and may have HF. The selection of atrial septal defect does not fit the question since the client is elderly, with chronic HF, and better fits the selection for atherosclerosis.
The nurse is caring for a client with mitral stenosis on the telemetry floor and notices a change on the telemetry monitor. The nurse expects which most common heart rhythm change based on the disease process? Ventricular fibrillation Sinus tachycardia Atrial fibrillation Sinus bradycardia
Atrial fibrillation A complication of mitral valve stenosis or mitral valve regurgitation is an arrhythmia that is created from disruption of the web of nerves that relay electrical impulses on the right atrium at the sinoatrial (SA) node. Mitral stenosis weakens communication pathways causing irregular and chaotic firing. Atrial fibrillation is the most common arrhythmia that arises from mitral valve stenosis. Other arrhythmias may occur from prolonged valve damage that may contribute to cardiac hypertrophy and stretching of chambers that may contribute to ventricular hypertension and arrhythmias.
The nurse is caring for a client who has been placed on long-term anticoagulation for management of intracardiac thrombi found on the echocardiogram. The nurse includes which health history reason for increased risk of intracardiac thrombi? Atrial fibrillation Pericarditis Pleural effusion Recent surgery
Atrial fibrillation Atrial fibrillation is correlated with intracardiac thrombus. Also, clients with cerebral ischemia are also at risk for intracardiac thrombus. Episodes of atrial fibrillation cause blood flow turbulence and slower flow within the atria along with "Virchow's triad" where blood coagulation, vessel wall factors, and reduced blood flow contribute to procoagulant states. Pericarditis, pleural effusion, and recent surgery are not priority reasons for intracardiac thrombi formation.
The nurse is caring for an older client who was admitted for extreme weakness, dizziness, and orthopnea. A diagnosis of heart failure is confirmed. Which of the following tests is a helpful in determining the diagnosis of heart failure? Electrolyte Panel Liver Function Panel 12-lead Electrocardiogram Brain Natriuretic Peptide (BNP)
Brain Natriuretic Peptide (BNP) The level of BNP increases with ventricular wall expansion, which occurs as a result of increased pressure. Natriuretic peptides are secreted by the heart as a way to balance and maintain homeostasis with blood pressure, plasma volume, and water/sodium ratios. It is secreted more when ventricles stretch or when chamber wall thickening occurs. BNP increases with straining of heart myocytes and is therefore a helpful tool in determining heart failure with or without systolic dysfunction. While potassium and sodium levels may present with imbalances they are not used to diagnose heart failure. While cardiac changes may be revealed through 12-lead ECG, such changes may not be diagnostic indicators of heart failure. The same holds true for liver function panels.
The nurse just received report from the cardiac catheterization team following a percutaneous coronary intervention (PCI) procedure. During the assessment, the nurse notices a blood soaked dressing and bleeding from the femoral artery access site. What action should the nurse perform first? Add another dressing layer on top of the saturated dressing. Raise the leg and place the client in trendelenburg position. Immediately pull on the femoral sheath until it is out of the femoral site. Call for help and apply pressure to the site immediately.
Call for help and apply pressure to the site immediately. The nurse should immediately call for help and apply pressure to the site. Adding another dressing over the saturated dressing will not stop the bleeding. Raising the lower extremity or placing the client in trendelenburg will not stop the bleeding. Increased bleeding and possible hemorrhage may occur if the femoral sheath is pulled out.
The nurse is caring for an older adult diagnosed with primary hypertension and is preparing an education plan for beta-blocker medication and management of hypertension while at home. Which health promotion education is most important for the nurse to include? Make sure to drink plenty of fluids to prevent dehydration. Change positions slowly, rise slowly, and use supports to prevent falls Do not engage in exercise until the medication is in the system for 6 weeks. Eat at least 2000 calories per day
Change positions slowly, rise slowly, and use supports to prevent falls Cardiovascular changes are associated with impaired cardiovascular reflexes and may cause postural hypotension that can result in dizziness and increase risk for falls. Teaching the client to change positions slowly, rise slowly, and use supports may help prevent accidental falls resulting from dizziness. The nurse should not instruct on fluid consumption as the client may have restrictions in fluids. The nurse should not instruct on holding off any exercise since light to moderate regular exercise may be beneficial. The nurse should not instruct on specific calories per day but should support teaching that includes fruits, vegetables, and low-fat dairy/milk products.
The nurse is preparing an individualized education plan for a client who has a history of smoking and is two days post cardiac surgery. Which information best addresses client education as an intervention for the nursing diagnosis of ineffective airway clearance related to pulmonary secretions? Client Teach-Back on low sodium diet Client teaching and demonstration of self-injection of lenoxaparin (Lovenox) Client teaching on the need for weekly PTT and INR for lenoxaparin therapy Client teaching and demonstration of deep breathing and coughing exercises
Client teaching and demonstration of deep breathing and coughing exercises Since the patient has a history of smoking, and the nursing diagnosis addresses ineffective airway clearance, the best choice is teaching and demonstration of deep breathing and coughing exercises. Breathing adequately assists in moving air to the lung bases, opens air passages, and helps mobilize mucous through effective coughing. Deep breathing and coughing also helps the blood and oxygen supply to the lungs, improving circulation. The client has risk factors of smoking, thus an important priority will be to assist with deep breathing/coughing. While low sodium diet is important, the nursing diagnosis and interventions are related to airway clearance. The question stem does not mention self-injection of lenoxaparin, and the client may be receiving a different type of anticoagulant while in the hospital setting. Weekly PTT and INR are not needed with low molecular weight heparin.
A client is admitted for observation following complaints of intermittent chest pain while mowing the grass. The pain persisted for an hour following the activity. All cardiac labs, electrocardiogram, and radiologic studies were normal and the client was provided nitroglycerin for a new diagnosis of angina pectoris. Discharge education includes information that angina is most often attributable to what cause? Decreased workload on the heart Atrial Septal defect Infarction of the myocardium Coronary arteriosclerosis
Coronary arteriosclerosis Arteriosclerosis affects coronary arteries because of narrowing of vessels that carry oxygen and nutrients from the heart to the rest of the bodies. Diminished oxygen from reduced blood flow in arteries supplying the heart muscle cause chest pain. Chest pain that is unrelieved may progress to myocardial infarction from sudden rupture of plaque or obstruction of blood flow. Angina is not caused by decreased workload on the heart. Decreased workload on the heart should be a goal for a client who learns behaviors and activities that reduce workload and improve cardiac pump effectiveness. Septal defects are not a common cause of angina.
A client is recovering from a heart transplant and asks the nurse why he must take Cyclosporine. How should the nurse best respond? Cyclosporine decreases the risk of thrombus formation by interfering with coagulation cascade. Cyclosporine minimizes rejection of the transplant and must be taken long-term. Cyclosporine increases contractibility of the donor heart. Cyclosporine helps prevent preload and afterload dysfunction in the cardiovascular system.
Cyclosporine minimizes rejection of the transplant and must be taken long-term. Cyclosporin minimizes rejection of the transplant. After heart transplantation, proinflammatory mechanisms are recruited into the cardiac allograft and leads to rejection. The medication is usually taken for life. Generally a three-drug therapy is utilized and Cyclosporin is one of the most common drugs used. The drug does not decrease risk of thrombus, nor does it change contractibility of the donor heart or affect cardiac preload or afterload.
The nurse caring for a client with dilated cardiomyopathy is scheduling a transthoracic echocardiogram, which might reveal what type of finding associated with the diagnosis? Decreased ejection fraction Decreased heart rate Presence of bundle branch block Asymptomatic ventricular tachycardia
Decreased ejection fraction Echocardiographic indicators that help diagnose and provide prognosis include left ventricular size and systolic function through ejection fraction among other results including right ventricular function, valve regurgitation function, left atrial volume index, and may include contractile reserve results when used with dobutamine stress echo. Echocardiograhic indicators do not rely on decreased heart rate, presence of bundle branch block or other heart irregularity such as V-tach for diagnostic consideration for dilated cardiomyopathy.
The nurse is caring for a client with a new prosthetic cardiac valve and is preparing discharge teaching. During discharge teaching, the nurse should provide education on the importance of antibiotic prophylaxis prior to which of the following? When exposed to influenza or pneumococcal pneumonia Prior to the next cardiac stress test Dental procedures Prior to any trip outside the United States
Dental procedures Phrophylactic antibiotics are recommended prior to dental procedures to help prevent infective endocardities which can occur following manipulation of gingival tissue or periapical regions of the teeth, or for injury to oral mucosa during dental procedures. Infective endocarditis occurs when bacteria from another part of the body enter and spread through the bloodstream and attach to areas of the heart. This spread may be the result of vegetation when endocardial tissue abnormalities induce deposits of fibrin and platlets which can lead to bacterial colonization.
The nurse is caring for a hospitalized client with admitting diagnosis of right-sided heart failure (HF). What assessment finding is most consistent with the client's diagnosis? Pulmonary edema Distended neck veins Dry hacking cough Orthopnea
Distended neck veins Right-sided heart failure occurs as a result of inefficient pumping of the right side of the heart, causing fluid buildup in the abdomen, legs, and feet. Excessive fluid causes weight gain, distended neck veins, and swelling of the liver. Heart rate may be irregular and a common arrhythmia with HF is atrial fibrillation. Pulmonary edema, orthopnea, paroxymal nocturnal dyspnea, and exertional dyspnea are symptoms of left-sided heart failure. Dry hacking cough is not a symptom of right-sided heart failure.
A nurse is caring for a client with venous disease in the lower extremities and is ordered radiologic testing. The nurse educates the client on which exam will likely be ordered for lower venous disease? Duplex ultrasonography Echocardiography Positron emission tomography (PET) Radiography
Duplex ultrasonography The duplex ultrasonography will determine how blood moves through the peripheral vessels by use of traditional ultrasonography with Doppler sonography. It helps with venous insufficiency to map out normal and abnormal venous pathways and to identify levels of obstruction of blood flow. Echocardiography examines the heart. PET and radiography are not determined to be the gold standard for determining evaluation of venous insufficiency.
The nurse is caring for a patient is admitted with a diagnosis of dilated cardiomyopathy. Assessment includes analysis of which laboratory results that would be used to prioritize assessment findings? Electrolyte panel, specifically sodium levels Kidney function panel, specifically GFR, Serum Creatinine, and BUN Liver function panel, specifically AST, ALT, and bilirubin White blood cell panel, specifically lymphocytes
Electrolyte panel, specifically sodium levels The cardiac sodium channel is important in the cardiac excitability and conduction system. In dilated cardiomyopathy dilation of the cardiac chambers and congested failure may occur. This is because cardiomyopahty is a disorder of the heart muscle that causes abnormal myocardial performance and is not usually the result of disease. Excess sodium will affect the heart since it cannot pump enough blood out to the body resulting in decreased cardiac output. Edema, pulmonary crackles, and irregular heart rate may occur, and treatment may include use of diuretics and sodium restricted diet. Types of cardiomyopathy include dilated, hypertrophic, and restrictive. Dilated cardiomyopathy is the most common form. Kidney and liver function may eventually be affected; however, neither are diagnostic for initial diagnoses. Having kidney or liver disease as may have a negative impact since they would be considered serious co-morbidities.
A nurse caring for a client with peripheral arterial insufficiency determined the nursing diagnosis of altered peripheral arterial insufficiency. Which intervention will be most appropriate for the client? Elevate his legs and arms above his heart when resting. Encourage the patient to engage in a moderate amount of exercise. Encourage extended periods of sitting or standing. Discourage walking in order to limit pain.
Encourage the patient to engage in a moderate amount of exercise. Expected interventions include ambulation for 10-15 minutes three to four times daily with gradual increasing of pace and duration. Regular exercise will be important. Elevation of arms and legs when resting is not the most appropriate intervention. Encouraging extended sitting or standing or discouraging ambulation will not improve peripheral neurovascular function.
The emergency department (ED) nurse is assessing a client who arrived with severe retrosternal chest pain described as burning and sharp which worsens on inspiration. The health care provider diagnoses the client with acute pericarditis. Which finding is most consistent with this diagnosis? Wheezes Friction rub Fine crackles Coarse crackles
Friction rub pericardial friction rub a predominant finding in acute pericarditis and has a scratching, grating sound similar to leather rubbing against leather. Auscultation is best heard with the diaphragm of the stethoscope over the left lower sternal edge or apex during end expiration while the client is sitting up and leaning forward. Wheezes are high pitched and may be during inspiration or expiration and are caused by constriction or swelling of airway and are not diagnostic for acute pericarditis. Fine or coarse crackles are caused by fluid in small airways and are discontinuous sounds created by air forced through narrowed respiratory passages caused by fluid or mucus and are associated with infection or inflammation. Fine crackles are soft, high-pitched while coarse crackles are louder and lower in pitch.
The nurse is caring for a patient who has right-sided heart failure, and is scheduled to receive the second dose of bumetanide (Bumex). Prior to administration of the drug, assessment of the client reveals a marked decrease from 4+ to 1+ ankle edema, neck distention is less than earlier, and the client lost 3 pounds in 24 hours. What action should the nurse take? Hold the bumetanide Give the bumetanide early Notify the physician Give the scheduled dose
Give the scheduled dose The nurse should give the medication as prescribed since the desired effect is to reduce ankle edema and prevent it from occurring. There is no reason to hold the medication, give it early, or to notify the HCP.
The nurse is caring for a client who has a rapid heart rate of 135 beats/minute and heart monitor reveals atrial fibrillation. Which of the following assessment findings would the nurse expect to find? GI distress Hypotension and distended neck veins Increased urinary output Hypertension and flat neck veins
Hypotension and distended neck veins Low cardiac output may occur with uncontrolled atrial fibrillation due in part from atrial kick. The client may have assessment findings of palpitations, chest pain, hypotension, fatigue, dizziness, syncope, shortness of breath, and distended neck veins. Flat neck veins indicate hypovolemia and GI distress is not an expected finding with tachycardia.
The nurse is caring for a client with telemetry heart monitor, and notices flat electrocardiographic complexes and occasional sinus rhythm. The monitor alarms sound when cardiac complexes become absent, and then alarms cease when sinus rhythm occurs. Which is the priority action by the nurse? Immediately go to the client's hospital room and assess telemetry lead placement Immediately call a Code and bring the crash cart to the client's room Immediately call the health care provider for pulseless electrical activity Immediately record the telemetry findings at the main telemetry station
Immediately go to the client's hospital room and assess telemetry lead placement The nurse should ensure that telemetry leads are placed appropriately, and while in the room, the nurse may assess condition of the patient such as level of consciousness, complaints of pain or palpitations, or other findings. Telemetry artifacts may appear like arrhythmias or even asystole. First confirm that the arrhythmia is real and check on the patient. Call a code if unstable. If stable and asymptomatic, and arrhythmia has been verified, call the health provider. Know policies and procedures.
The nurse is caring for a client who is prescribed hydrochlorothiazide for hypertension. Following administration of this medication, the nurse should anticipate what effect? Increased blood pressure related to increased cardiac output Increased urine output related to diuretic effect Elevated potassium Mild agitation
Increased urine output related to diuretic effect Hydrochorothiazide is prescribed for management of mild to moderate hypertension and edema. Therapeutic effects occur with lowering of blood pressure and diuresis for mobilization of fluid volume. Therefore, increased urine output related to the diuretic effect will occur. The drug may cause a decrease in potassium, not an increase (as in spironolactone, a potassium sparing diuretic). Mild agitation is not a common adverse reaction.
The nurse is caring for a post-surgical client. During the assessment, the client complains of sudden onset of pain to the right lower leg. The right lower leg is swollen, reddened, and warm to touch. What is the most appropriate action by the nurse? Administer 10,000U dose of subcutaneous heparin followed by continuous IV Heparin. Inform the physician that the client has signs and symptoms of venous thrombosis. Ambulate the client immediately to restore circulation. Place heating pad to right leg for 15 minutes followed by smaller size compression stockings.
Inform the physician that the client has signs and symptoms of venous thrombosis. The correct action is to inform the healthcare provider. The nurse may expect to administer heparin or other anticoagulant; however, such an order may not be obtained without consulting with the provider. Ambulating may cause the clot to break off and enter the circulation. Placing heat followed by tight compression stockings is not a priority action, and may cause the clot to break off.
The nurse is caring for a patient with severe left ventricular dysfunction and understands the client is at risk for sudden cardiac death. The nurse anticipates which medical intervention? Insertion of an implantable cardioverter defibrillator Insertion of an implantable atrial pacemaker Administration of thrombolytic agents Cardioversion under light anesthesia
Insertion of an implantable cardioverter defibrillator Clients who have reduced left ventricular ejection fraction (LVEF) and dysfunction (especially if they experienced MI) are at increased risk of sudden cardiac death (SCD). Implantable cardioverter defibrillators (ICD) provide significant survival benefit. Atrial pacemaker, thrombolytic agents, or cardioversion are not treatments for ventricular dysfunction and risk of sudden cardiac death.
The nurse is caring for a client who required insertion of an automatic internal cardioverter-defibrillator and is preparing information for home management and safety. Which information by the nurse is most important for client instruction? Self-management of anxiety through biofeedback. Keeping a log of activities that occur near electromagnetic sources. Encouraging swimming alone as a healthy activity. Instruction on use of a Medic-Alert device.
Instruction on use of a Medic-Alert device. The client should always wear a Medic-Alert device such as a medic alert necklace or bracelet, and an ID card that states the client has an ICD. While the client should avoid machines that have magnetic fields (such as MRIs), there is no reason to log them. Swimming may be restricted by the healthcare provider for a period of time; however, if allowed, clients must not swim alone. Using biofeedback for anxiety is not the most important instructional topic. Safety and management of the ICD are most important.
The nurse is assessing a client who reports pain to the left lower extremity, especially while ambulating. The discomfort is relieved with rest. Assessment findings confirm left lower leg 3+ edema, hairless, and mottled in color. Which health problem will the nurse most likely include in the planning of the client's care? Coronary artery disease (CAD) Intermittent claudication Arterial embolus Raynaud's disease
Intermittent claudication Claudication occurs when blood flow is narrowed to peripheral circulation. It may occur during exercise or movement, depending on where the arterial narrowing is located. Signs are pain relieved by ceasing the activity (intermittent pain); however, in advanced stages pain occurs at rest; discolored skin or ulcerations from reduced blood flow (and cool to touch); and achy or burning sensation. Peripheral artery disease (PAD) is linked with intermittent claudication versus CAD. Arterial embolus and Raynaud's do not correlate with findings from assessment or health history.
The nurse is caring for an acutely ill patient with a history of renal insufficiency who is on anticoagulant therapy. What will the nurse anticipate in the individualized plan of care for the heparin therapy? Heparin is contraindicated in the treatment of this patient. Heparin may be administered subcutaneously, but not IV. Lower doses of heparin are required for this patient. Coumadin will be substituted for heparin.
Lower doses of heparin are required for this patient. Clients with renal compromise have a higher risk of both thrombotic and/or bleeding complications because of renal clearance of the drug. Dose adjustments such as lower dose of heparin will be required. Route of administration of heparin will not influence the plan of care for renal insufficiency. Heparin is not contraindicated; however, it must be dosed correctly and monitored frequently. Coumadin does not need to replace heparin.
The nurse is caring for a client diagnosed with pre-hypertension. The nurse initiates what type of instruction for lifestyle changes that may help prevent progression of the hypertension? Avoid foods high in potassium and carbohydrates. Maintain exercise on a regular basis for at least 30 minutes. Limit protein and gradually progress to vegetarian lifestyle. Limit strenuous activities to non-aerobic, non-weight bearing.
Maintain exercise on a regular basis for at least 30 minutes. The client should maintain an exercise regimen on a regular basis. The client should observe sodium intake more than potassium intake, unless the client is also on spironolactone (a potassium sparing diuretic). Limiting protein and having vegetarian lifestyle is not recommended; however, having a dietary protein intake especially from plant sources may be beneficial in helping to lower blood pressure. Lack of exercise and non-aerobic, non-weight bearing are not beneficial.
The nurse is caring for a client in Intensive Care Unit for myocardial infarction. The client has a 18 gauge peripheral IV site and will utilize the site for starting an intravenous nitroglycerin infusion. The nurse understands that intra-arterial monitoring of blood pressure is preferred for monitoring; however, until the arterial line is established, the nurse will monitor the patient using which type of equipment? Noninvasive blood pressure monitor will be utilized. Central Venous Pressure gauge will be utilized. The nurse will hold the Nitroglycerin infusion until arterial line is inserted. Pulse oximeter connected to monitor console
Noninvasive blood pressure monitor will be utilized. Nitroglycerin infusions are indicated for myocardial infarction since the drug dilates vessels with goal of reducing myocardial effort by decreasing preload and afterload, and increasing myocardial oxygen supply. Hypotension is the main side effect due to dilation. Infusion of nitroglycerin may be titrated for chest pain and blood pressure. Clients should be in a controlled setting with continuous monitoring of cardiac and frequent blood pressure. Blood pressure must be monitored frequently and each time a titrated dose is changed. While arterial pressures are often used in the Intensive Care Unit, blood pressure may be monitored via noninvasive devices. The nurse should NOT hold the medication. Oximeter does not measure blood pressure response to nitroglycerin. Central Venous Pressure (CVP) is a reflection of preload and may guide decisions regarding fluid volume status, and CVP entails insertion into central venous system (via jugular or subclavian).
A client with coronary artery disease (CAD) requires education on risk factors that can be controlled or modified. Which of the risk factors will the nurse indicate that are controlled or modified? Gender, obesity, family history, and smoking Genetics, smoking, inactivity, and gender Drinking alcohol, stress, gender, and smoking Obesity, inactivity, diet, and smoking Obesity, stress, genetics, and ethnicity
Obesity, inactivity, diet, and smoking Risk factors of obesity, inactivity, diet, and smoking are modifiable or controlled. Other choices include non-modifiable or uncontrolled factors such as gender, genetics, and ethnicity.
The nurse is assigned five clients on the medical floor of the hospital. The hospital's infection control committee is creating a proactive program to identify clients at risk for hospital acquired infective endocarditis. Which of the five clients would be most at risk for hospital-acquired infective endocarditis? Patients with kidney failure and receiving in-hospital dialysis. Oncology patients who just received immunotherapeutic agents. Clients out of the Intensive Care Unit who were treated with thrombolytics All pediatric clients being treated with IV antibiotics.
Patients with kidney failure and receiving in-hospital dialysis. Infective endocarditis in clients receiving hemodialysis is significantly more common and causes greater morbitiy and mortality than in other populations. For this reason, attention must be made for healthcare associated dialysis infective endocarditis. Hemodialysis clients are prone to bacteremia, particularly staph, strep, and enterococcus bacteria. While oncology patients, post ICU patients, and pediatric patients are at risk for infection, hemodialysis clients have higher risk for infective endocarditis.
client remembers. The client also states that lunch on the job consists of fast food and does not have time to fix a lunch in the mornings. After assessment and analysis, the nurse has identified a nursing diagnosis of risk for ineffective health maintenance related to nonadherence to therapeutic regimen. Which type of teaching/education would benefit the client most? Ask the client if there is a death wish because of the noncompliance then proceed to ask why the client does not want to live to see grandchildren. Give the client free movie tickets for blood pressure less than 150/80 with the next visit and increase the incentive for the next three visits. Provide written education materials, Teach-back, med-minder log, and a list of foods that are low salt and low fat that can be ordered in restaurants near work. Provide medical journal articles on recent research in early death, mortality, and co-morbidities with hypertension and heart disease.
Provide written education materials, Teach-back, med-minder log, and a list of foods that are low salt and low fat that can be ordered in restaurants near work. The client requires education that entails feedback, materials to refer to that are easy to read and understand, and assistance and help in how to remember medications. The client may change food choices and/or locations of places to eat for lunch while at work. Coercion with awards and gifts may not help the client reach lifestyle changes for long-term. Confronting the client with death wish is non-therapeutic.
A client has a new prescription captopril (Capoten) following a clinic visit. What should the nurse include in teaching about the drug? (Select all that apply.) Take the medication with meals Report any cough that develops. Report to the clinic for weekly blood serum labs. Check blood pressure prior to dose, log findings, and report changes.
Report any cough that develops. Check blood pressure prior to dose, log findings, and report changes. The patient should check blood pressure weekly; report cough, swelling of the hands, feet, or tongue, or difficulty swallowing. It is not necessary to take captopril with meals. Photosensitivity is not an issue and weekly laboratory tests are not necessary.
The nurse is performing an assessment on a client with a history of cardiovascular disease, diabetes, hypertension, and hypothyroidism. The client is experiencing exhaustion with simple activities of daily living and short ambulation, and states a 5 pound weight gain over 4 days. Assessment reveals 4+ edema to lower extremities and jugular distention. The nurse will report findings to the health care provider and anticipates which medical condition? Acute pericarditis Myocardial infarction Left-sided heart failure Right-sided heart failure
Right-sided heart failure The client exhibits signs of right-sided heart failure because fluid is being retained (weight gain), and is backing up systemically. The patient is fatigued due to diminished cardiac output and reduced oxygenation, and has jugular venous distention. Acute pericarditis often presents with pain that may be intense on inspiration, low-grade fever, heart palpitations, and although pericarditis may result in fluid collection around the heart, the answer does not fit the complaints and findings of the client. Left-sided heart failure may present with pulmonary congestion, dry cough, and orthopnea, but differs from right sided HF. Myocardial infarction does not fit the signs and symptoms or assessment findings.
The emergency department (ED) nurse assessed a client with complaint of headache for the past two days. Blood pressure on admission to the ED was 196/114 and second blood pressure was 188/100. The ED nurse administered hydrochlorothiazide followed by losartan. Five hours later the blood pressure was reduced by 10% and complaints of headache lessened. The ED nurse provided instructions based on follow-up for which type of hypertension? Pre-hypertension Stage 1 hypertension Stage 2 hypertension Stage 3 hypertension
Stage 2 hypertension The client presents with Stage 2 hypertension. Stage 2 systolic is 140 or higher and diastolic is 90 or higher. Stage 1 presents with systolic between 130-139 and diastolic between 80-90. There is no stage 3 hypertension; however, there is a hypertensive crisis which occurs with systolic higher than 180 and diastolic higher than 120. The goal of treatment was to reduce the blood pressure gradually. Stage 2 hypertension may benefit best with a combination of anti-hypertensive drug combination with a diuretic. Angiotensin-receptor blockers (ARBs) blocks angiotensin II from constricting blood vessels and stimulating sodium and fluid retention. Diuretic like hydrochorothiazide will help lower blood pressure through urinary output and its action is enhanced with concomitant use of ARB.
Part of the plan of care for a client who recently received mechanical valve prosthesis is discharge education for home management. Which information will the nurse determine to have the most priority? The need to reschedule valve replacement within 5 years Report near high or low blood pressure and heart rates Strategies for preventing atherosclerosis Strategies for infection prevention
Strategies for infection prevention A priority education need is for infection prevention strategy because of the risks for infective endocarditis. Teaching will include notifying the health provider for increased temperature, sore throat, need for prophylactic antibiotics prior to dental procedures, and if exposure to others with illness has occurred. Strategies for prevention of atherosclerosis' are important, but are not a priority for immediate management of post-surgical and life-long management of valve prosthetics. Teaching on infection prevention has higher priority than reporting borderline heart rate and/or blood pressure Reporting high or low heart rates (above and/or below parameters set by the healthcare provider—not only borderline findings), palpitations, chest pain, shortness of breath, fluctuations in blood pressure, dizziness, and syncope are important to report.
The nurse is caring for a young adult client following a balloon valvuloplasty of the aortic valve. During the post procedure assessment, the nurse monitors for which complications related to valvuloplasty.? (Select all that apply) Sudden cardiac arrhythmia Emboli Sudden mental status changes Redness near the radial vein access site
Sudden cardiac arrhythmia Emboli Sudden mental status changes Complication of sudden cardiac arrhythmia such as atrial fibrillation and heart block are risk factors along with emboli from invasive vascular access and coagulation that may require anticoagulants postoperatively. Sudden mental status changes such as delirium may occur following post procedure which may result from nigher microembolic load, neuroinflammation in the brain, cerebral hypoperfusion, and alteration of cerebral acetylcholine levels. Nursing actions should include frequent reorientation strategies and neuro assessments immediate post-operatively. Redness near the venous access site is incorrect since the access is arterial not venous. The most common site is femoral artery.
The nurse is caring for a client with heart failure who is receiving a prescribed angiotensin-converting enzyme inhibitor (ACEI). The patient is asking how the drug works for heart failure. What will the nurse include in teaching the client about this medication? (Select all that apply.) The ACEI reduces fluid volume The ACEI relaxes blood vessels and lowers blood pressure The ACEI reduces workload on the heart The ACEI decreases pulmonary venous pressure.
The ACEI relaxes blood vessels and lowers blood pressure The ACEI reduces workload on the heart ACEIs are considered the first-choice drug over angiotensin receptor blockers (ARBs). ACEIs block the action of an enzyme that causes narrowing of the heart vessels, and as a result, the vessels relax and widen. As a result, ACEIs have a vasodilation effect, which lowers blood pressure and reduces workload on the heart. They also offer additional benefit by preventing remodeling, which is an effect that leads to progressive cardiac deterioration. ACEIs do not reduce fluid volume or decrease pulmonary venous pressure; however, diuretics reduce fluid volume and decrease pulmonary venous pressure. Some ACEIs are combined with diuretic therapy. The question is specific for just ACEIs and not ACEIs/Diuretic combinations.
The nurse is scheduling a client for a cardiac catheterization. The client has type 2 diabetes and takes metformin. Which action will the nurse take prior to scheduling the procedure? The nurse will instruct the client to have fasting A1C and glucose tolerance test prior to the procedure. The nurse will instruct the client to eat a low carbohydrate diet three days prior to the procedure. The nurse will instruct the client to hold the metformin for 24 hours before the procedure and 48 hours after the procedure. The nurse instructs the client to take all medications the morning of the procedure but not to drink or eat afterwards.
The nurse will instruct the client to hold the metformin for 24 hours before the procedure and 48 hours after the procedure. Metformin (Glucophage) will cause the client to be at risk for lactic acidosis if the client take the medication with injection of contrast medium. The contrast medium may affect kidney function, and metformin in the system may increase risk of lactic acidosis. Holding the drug 24 hours prior and 48 hours following the procedure will minimize complications.
The nurse performs admission assessment for an older client admitted to the telemetry floor. The client's history reveals type 2 diabetes, mitral valve prolapse, and hypertension. Which assessment information is an important indication of risk for heart failure (HF) (Select all that apply)? The patient takes furosemide (Lasix) 20 mg/day. The patient's potassium level is 4.7 mEq/L. The patient is an African American man. The patient's age is greater than 65.
The patient is an African American man. The patient's age is greater than 65. Prevalence of HF increases with age and having other conditions such as diabetes and hypertension may increase risks for having HF. Studies have revealed HF risks in African American men and women because of higher linkages with ethnicity and other co-morbidities that may contribute to heart disease and HF. Other risk factors are obesity, elevated cholesterol, smoking, and ischemic heart disease. Potassium levels do not indicate HF, and the level indicated in selection B is within normal range. While some clients take loop diuretics such as furosemide for HF, the drug may also be used for other reasons.
The nurse is caring for a patient diagnosed with peripheral arterial occlusive disease (PAD). What assessment finding is most consistent with this diagnosis? Thick, tough, brownish pigmented skin to extremities Unequal peripheral pulses between extremities Complaints of pain relieved by elevation Diffuse varicosities along back of legs bilaterally
Unequal peripheral pulses between extremities Peripheral pulse changes may be diminished to absent in affected limb with PAD. Other changes are skin color with mottled pallor which worsens when elevated and rubor when dependent, pain, loss of hair on lower extremity, dry scaly skin, and paresthesia. The other selections are characteristic of venous insufficiency versus arterial insufficiency.
The nurse is caring for a client with an open lower extremity leg ulcer. The wound margins are irregular, wound bed is red, and is draining moderate amounts of thick exudate. The nurse documents which type of ulcer? Arterial ulcer Venous ulcer Edema ulcer Wound ulcer
Venous ulcer Venous ulcers are caused from venous insufficiency. The condition is caused by a problem with blood return not blood flow. The blood pools in the lower leg because it cannot get back to the heart. Venous ulcers usually have irregular wound margins, weepy edema from pooling and may have a purple/brown color called hemosiderin staining from pushing cells out of the capillaries (that release iron). Drainage is usually moderate to heavy. The description in the question does not represent arterial ulcer, which are opposite from venous ulcers. Blood return is not the issue, but flow is the big problem as blood cannot go to the area. As a result, water and nutrients cannot be transported and the area will have little exudate, pale, cool to touch, and cyanotic form lack of oxygen. The area may also be hairless. Arterial ulcers may have necrotic tissue or pale tissue (because of lack of blood), may be round with "punched out" look and may occur on outer malleoulus and toes.
The nurse is providing discharge education on fluid balance monitoring to a patient with a new diagnosis of right-sided heart failure. The nurse will stress which priority instruction for monitoring fluid balance? Weigh daily at the same time in similar clothing Take self-pulse rates and report findings below 60 Take blood pressure at the same time daily Bowel movements should be logged
Weigh daily at the same time in similar clothing Instruction of daily weights is important in assessing fluid balance with HF. Clients should report edema or weight gain to the HCP. It is important to monitor heart rate and blood pressure (especially if taking certain cardiovascular medications like ACE inhibitors, lanoxin, low-dose beta-blockers, or diuretics); however, assessing weight is best for monitoring fluid balance.
The nurse is providing education for a client diagnosed with angina pectoris. Further education is needed after the client verbalizes which statement after teaching is provided? "I know that exercise may increase the heart's oxygen demands, and may cause angina; however, moderate exercise is beneficial." "Exercise must be avoided at all costs, and I will be more comfortable in my chair during the day." "I can log symptoms and activities that precipitate angina attacks." "If I experience angina, I will stop the activity and sit or lie down to reduce oxygen requirements until the pain subsides."
"Exercise must be avoided at all costs, and I will be more comfortable in my chair during the day." All of the answers are appropriate for the client's management of angina after discharge except the selection regarding avoiding exercise (selection B). The client needs more information and education for statements that indicate ceasing of activity and exercise. Light to moderate exercise on a regular schedule is beneficial and has a positive effect on contributing factors of heart disease. Exercise increases blood and oxygen flow to the heart while at rest and while performing other activities.
